M. Alcalay

A prospective study of high‐ versus low‐dose oxytocin for induction of labor

Background. To assess the efficacy and safety of a high‐dosage oxytocin induction regimen.

Successful Pregnancy in a Patient With Polycystic Kidney Disease and Advanced Renal Failure: The Use of Prophylactic Dialysis

Adult polycystic kidney disease is an inherited disease that is transmitted as an autosomal dominant trait. The clinical manifestations, which develop during the third or fourth decade of life, usually do not affect women during childbearing age and thus do not affect fertility or pregnancy outcome. The patient presented here had polycystic kidney disease and advanced renal failure, and was treated with meticulous fetal surveillance and prophylactic hemodialysis during pregnancy. The successful outcome strengthens the trend to perform prophylactic dialysis in pregnancies with advanced renal failure, despite the lack of controlled studies.

Three-dimensional transperineal ultrasound for imaging mesh implants following sacrocolpopexy.

To characterize, using three‐dimensional (3D) transperineal ultrasound, the appearance, position and dimensions of mesh implants following minimally invasive abdominal sacrocolpopexy.

OP34.05: Obstetric anal sphincter injury—how does a subsequent delivery affect long term outcome?

group women. Right-sided injury was seen twice as often as left, 32% vs. 16%; injury was bilateral in 2 patients (4%). In controls, 44/247 (18%) showed signs of levator ani disruption (P < 0.01); none were bilateral. Conclusions: III◦ or IV◦ anal sphincter tears pose increased risk for trauma of the anterior compartment. Although this risk factor cannot be modified to prevent LAM injury, it is a possible indication for thorough sonographic evaluation of the anterior compartment.

Mesh pullout force: comparative study of different deployment techniques in a sheep model.

Introduction and hypothesisPullout force of mesh from tissue is one of the important mechanical properties of an implanted mesh to repair pelvic organ prolapse (POP). The EndoFast Reliant™ system kit allows mesh attachment with soft-tissue fasteners. The aim of this study was to compare the pullout force that developed in mesh that was attached by EndoFast Reliant fasteners to mesh that was attached by trocar-based methods (tunnel, pocket) in a sheep model.MethodsSix sheep underwent mesh attachment with three methods (EndoFast Reliant, tissue pocket, tissue tunnel), and each method was repeated five times in both thighs of the same sheep. The pullout force was measured at different time intervals from surgery: 0, 3, 7, 15, 30, and 45 days. Statistical analysis was performed by using the appropriate one-way analysis of variance (ANOVA) for each time interval and a general linear model for repeated measures using IBM® SPSS® software version 20.0.0.ResultsDuring the immediate postoperative period (0–3 days), pullout force was significantly higher with EndoFast Reliant than with tissue pocket or tissue tunnel. At day 7, this trend continues without statistical significance. Pullout force increased progressively until day 15, when the force caused the mesh to tear; it was similar in all three groups. ANOVA showed significant effect of time and study group.ConclusionsThe EndoFast Reliant system provides significantly stronger attachment in the immediate postoperative period (0–3 days) compared with trocar-based techniques, and this difference disappeared at day 15 postsurgery.

OC29.04: Risk factors for levator avulsion trauma in women with obstetric anal sphincter injuries

Objectives: In 10–30% of women, vaginal birth results in levator ani tears which are associated with female pelvic organ prolapse and reduced contraction strength in later life. This study was undertaken to determine whether women notice such changes after childbirth. Methods: This is a retrospective analysis of two perinatal imaging studies. Patients were followed up 3–6 months postpartum. They were asked to estimate pelvic floor strength relative to strength just before childbirth, using a percentage. Translabial 4D pelvic floor ultrasound was performed to determine structure and function of the levator ani muscle. Imaging analysis was performed offline, using proprietary software, blinded against all clinical data. Levator avulsion was diagnosed on tomographic imaging in the axial plane. Results: 513 primiparous women were seen for follow-up in the context of two prospective trials, at a median of 129 days postpartum. They had given birth to a singleton at a mean gestation of 40.0 (range, 36+0 to 42+5). There were 351 vaginal deliveries (27 Forceps, 60 Vacuum and 264 NVD) and 162 Caesareans (31.6%). At follow-up, 482 were able to rate their pelvic floor strength relative to the situation prior to childbirth, reporting an average strength of 89%. This reduction was associated with delivery mode (P < 0.001), length of 2nd stage (P = 0.017) and episiotomy (P = 0.019). 45 women were diagnosed with levator avulsion which was associated with a greater reduction (no avulsion, 90% vs., unilateral avulsion, 86%, bilateral avulsion 80%, P= 0.007 on ANOVA). Conclusions: Many women notice altered pelvic floor function after childbirth. Vaginal childbirth, episiotomy, perineal tears and length of 2nd stage are associated with subjectively reduced pelvic floor strength after first delivery. Women who have suffered a levator avulsion notice a significantly greater reduction in subjective strength.

OP23.04: Validation of transperineal ultrasound examination in the evaluation of urogynecological patients

Objectives: To evaluate the correlation between levator ultrasound morphology and pelvic floor pathology. Methods: A standardized pelvic floor questionnaire, physical examination (Baden–Walker classification), and multi-channel urodynamic testing (MMS, Holland). 2D, 3D and 4D transperineal ultrasound with a 4–8-MHz transabdominal probe, at rest, maximal Valsalva, and maximal contraction. Statistical analysis using SPSS software. Results: Forty-eight women were analyzed, median age 53 years. Levator avulsion defects were found in 79%, 19% right, 8% left and 52% bilaterally. In cases of bilateral avulsion, 28% had a larger avulsion defect on the right. Levator biometric indices are given in the Table. Levator ballooning (hiatal area ≥ 300 mm2) was observed in 4.5% of women at rest and 46.8% of women at maximal Valsalva. Levator ballooning at Valsalva correlated weakly with prolapse sensation (r = 0.32, 0.04 Fisher exact test) and voiding difficulty (r = 0.31, P = 0.04), but not with prolapse grading. Range and median of the ratios of the various biometric indices between maximum Valsalva and rest are shown in the Table. The Valsalva to rest ratio for the levator area at the genital hiatus was significantly larger than the other ratios. The Valsalva to rest ratio for area showed a weak correlation with prolapse sensation (r = 0.41, P = 0.01, Fisher exact test) and rectocele grading (r = 0.4, P = 0.012, Pearson Chi square). Conclusions: Levator ani defects are very common in patients with pelvic floor problems. The ratio between the levator areas at maximal Valsalva and at rest correlates with several prolapse symptoms and physical findings, and may represent the tissue elasticity of the levator ani. More research is needed to establish its significance to patient management and outcome.

OC30.04: Does the levator ani change in appearance?

Objective: Several mechanisms are believed to be in play maintaining anal continence, one of them being voluntary squeezing using the pelvic muscles. Here we study the effect of squeeze on the anal channel position and dimensions. Method: 20 healthy 0-gravida and 24 women with anal incontinence were recruited after written consent for 3D vaginal ultrasound measurements of angles and diameters during rest and squeeze. The anovaginal angle was defined as the angle between the posterior vaginal wall and the anterior wall of the channel assessed in a sagittal section. The anorectal angle was defined as the angle between the posterior wall of the anal channel and that of the rectal wall above the level of the puborectal muscle. Diameter and area of the mucosa were measured in the middle of the anal channel (lower level) and at the level of the puborectal muscle (upper level). Results: The 0-gravida had a mean age of 26 years with an incontinence score 0 on a scale 0–24. The incontinent women had a mean age of 59 years and their score was mean 11 (range 3–22). The ultrasound measurement results are presented in the table. Conclusion: Voluntary squeeze augments the bend of the anal and rectal tube at the level of the puborectal muscle and compresses the mucosal cuff at this level in young 0-gravida women. In incontinent women of a higher age, the anal tube is straighter, the mucosal cuff in the lower anal channel is smaller, and the effect of squeeze is less prominent or lacking.

Use of ultrasound in the clinical evaluation of women following colpocleisis

To assess the role of transperineal ultrasound in the postoperative evaluation of patients undergoing colpocleisis.

P26.08: The urethral lumen on 3D transperineal ultrasound volumes—does it mean anything?

Early US lenght, there was a marked reduction in midsagittal mesh length 90.3 (SD 1.8) mm vs. 57.1 (SD 10.0) mm, P < 0.001. When early and late ultrasound measurements were compared (n = 30, Time Point 1–2), we observed a further reduction of about 15% in midsagittal dimensions [57.1 (SD 10.0) mm vs. 48.3 (SD 10.2) mm, P < 0.001]. The Inter-observer realiability series showed ICC for Early US length 0.74 and 0.82 for Late US length. Conclusions: The degree of shrinkage corresponds with data from experimental animal studies, where shrinkage was between 15%. We should point out that the surgical impact on final mesh length is markedly greater than shrinking. We should be using imaging to monitor our surgical results as standard.